Nightmare Disorder

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This article refers to the International Classification of Diseases 11th edition (ICD-11) which is the official classification system for mental health professionals working in NHS clinical practice. The literature occasionally refers to the Diagnostic and Statistical Manual of Mental Disorders (DSM) classification system which - whilst used in clinical practice in the USA - is primarily used for research purposes elsewhere.

Nightmares can be defined as vivid and terrifying dreams which awaken the dreamer from sleep. Typically, the dreamer wakes from the rapid eye movement (REM) stage of sleep and can remember a detailed, perhaps bizarre dream plot. There is evidence that frequent nightmares are associated with insomnia and poor-quality sleep.[1]

Although such dreams are part of normal human experience, for some they can be a recurrent and extremely troubling problem. This is particularly so for young children, but they can be disruptive to the whole family. Explanation and reassurance are often helpful particularly for parents who can then in turn be more reassuring to the affected child.

It is important to distinguish nightmare disorder from night terrors (which are episodes of panic and confusion, with difficulty waking or bringing to awareness, and of which the sufferer has no recollection). The ICD-11 definition of the diagnosis of a nightmare disorder is detailed below:

ICD-11 definition of the diagnosis of a nightmare disorder[2]

7B01.2 Nightmare disorder

Nightmare disorder is characterised by recurrent, vivid and highly dysphoric dreams, often involving threat to the individual, that generally occur during REM sleep and that often result in awakening with anxiety. The person is rapidly oriented and alert upon awakening.

Nightmares are common, particularly in children.

Children[3]

  • 10-50% of those aged 3-6 years are estimated to suffer from nightmares that disturb their sleep, or that of their parents.
  • They normally start between the ages of 2-5 years.
  • A cross-sectional study of 4- to 12-year-olds suggests a peak prevalence between 7 and 9 years, with 87% and 95.7% of children retrospectively reporting bad dreams often or sometimes.[4]

Adults[5]

  • A literature review reports that up to 85% of adults report at least one nightmare within the previous year, 8-29% report monthly nightmares and 2-6% report weekly nightmares.
  • Older people were 20-50% less likely to have nightmares than young people.

Several research groups have proposed that nightmare disorders result from increased hyperarousal and impaired fear extinction.

  • Hyperarousal may develop during the day and be maintained at night. Hyperarousal is central to the pathophysiology of PTSD and insomnia.
  • Normal sleep and dreaming may lead to fear extinction by recombining fear-inducing memories with novel and dissociated contexts. However, people with nightmare disorder continue to activate distressing and arousing memory fragments during sleep, reinforcing memories of fear. Individuals who have experienced stressful and negative-emotion-eliciting events may be particularly prone to this, as are those who have a tendency to react to stressors with distress and negative affect.

Factors hypothesised to lead to hyperarousal and impaired fear extinction include:

  • Traumatic experiences and childhood adversity (disrupting emotional regulation).
  • Differential susceptibility: some individuals are more sensitive to both positive and negative stimuli, leading to an increased likelihood of emotional and affective distress and nightmare disorder.
  • The development of maladaptive beliefs, such as thought suppression (attempting to suppress unwanted thoughts and feelings), which increases the likelihood of those thoughts recurring in dreams.
  • Sleep fragmentation due to obstructive sleep apnoea and other sleep-related hypoventilation syndromes.
  • Medications that influence neurotransmitter activity and function.

Drugs linked to nightmares[7, 8]

  • Antihypertensives:
    • Beta-blockers (the water-soluble beta-blockers such as atenolol are less likely to cause nightmares, as they are less likely to cross the blood-brain barrier).[9]
    • Centrally acting antihypertensives.
  • Antidepressants: selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants and monoamine-oxidase inhibitors( MAOIs).
  • Anti-Parkinsonian agents: levodopa, selegiline.
  • Sedatives:
    • Ketamine[10]
    • Short-acting barbiturates
  • Miscellaneous:
    • Rauwolfia alkaloids
    • Alpha-agonists
    • Flutamide
    • Procarbazine
  • Medication withdrawal: benzodiazepine or alcohol withdrawal leads to a rebound of REM sleep which may increase nightmares.

It is theorised that recurrent nightmare elements may then become condensed into a 'nightmare script', where dream elements trigger the nightmare to occur. Nightmares may, therefore, persist long after the initial stressor has subsided.[6]

  • Nightmares tend to start in the latter half of the sleep cycle, during REM sleep.
  • The nightmare usually involves a threat of danger. This may be a physical threat such as being pursued, or a psychological one such as being teased. Frequent threatening characters for children are monsters, ferocious animals, ghosts, bullies or 'bad' people.
  • It is unusual for the person to shout out, move or have autonomic disturbance during the experience, although these things may occur to a minor degree.
  • When awoken it is usual for the person to be orientated, alert and responsive and to be receptive to calming by their parents/others. The details of the dream are usually remembered. This contrasts with night terrors where the person may be difficult to rouse and may not recall what has been troubling them.
  • There may be a family history of similar problems.
  • Take a careful history, preferably also from parents, carers or relatives who have witnessed the event.
  • Assess whether mental impairment, mental illness, depression, other central nervous system (CNS) disease or a febrile illness could be contributing.
  • Consider medication history and alcohol/benzodiazepine withdrawal.
  • Ask if there has been any recent traumatic event or conflict/stress.
  • Night terrors - the difference from nightmares is that: they tend to occur earlier rather than later during the night; the person may initially be unresponsive or disorientated; unlike nightmares, they usually cannot recall the event; signs of autonomic arousal such as dilated pupils, tachypnoea and tachycardia are more likely. See related separate article Night Terrors and Parasomnias.[5]
  • Underlying organic brain disorder - eg, delirium or mental impairment.[11]
  • Post-traumatic stress disorder (PTSD): nightmares are a feature of PTSD. However, in PTSD the dream content often involves reliving the trauma and there are other symptoms such as poor sleep and daytime anxiety.[12]
  • Medication or withdrawal from medication.[13]
  • Recurrent febrile illness causing delirium or predisposing to nightmares (this may also cause night terrors).[14]
  • Seizures.[15]
  • Depressive illness with melancholic features may be associated in adults.[16]
  • REM sleep behaviour disorder (a problem affecting particularly older adults).[17]

Investigations are not usually necessary if the diagnosis is clear from the history. However, bear in mind that:

  • Physical sleep disorders such as obstructive sleep apnoea and other types of sleep disordered breathing may coexist.[18] If these problems are suspected, or the diagnosis is unclear, assessment at a sleep clinic may help.[19]
  • If there is reason to suspect an underlying cause then electroencephalogram (EEG), blood tests and CNS imaging may be considered.
  • Reassurance of the patient or child and parents is all that is usually required.
  • Helpful tips for children:
    • It may help to develop a relaxing bedtime routine that does not vary. Attention to causes of stress and upheaval within the home may help reduce the propensity to nightmares.
    • Use of night lights and other strategies that may reduce a child's anxiety levels at night can help.
    • If the nightmare is recurrent then it may help for the parents to talk through the nightmare and imagine a less scary ending.
  • If the problem is occurring, say, on a more than twice-weekly basis persistently, then it may be worth referring for psychological or child-psychiatric input.
    • Cognitive behavioural therapy may be beneficial.
    • There is evidence that psychological techniques such as imaginal confrontation with nightmare contents or imagery re-scripting and rehearsal may be helpful.[20]
  • Drug treatment is not usually helpful and is more likely to cause nightmares. (This contrasts with some other types of sleep disorder, where medication may help.) However, in persistent cases, an REM-suppressant drug such as a tricyclic antidepressant may be helpful.
  • Prazosin may be helpful for nightmares associated with PTSD,[21] although there are reservations about conflicting data.[6]

In children, the prognosis is very good. The symptoms should resolve as time passes and after reassurance of the child and parents that this is a relatively normal experience for some young children. If the symptoms persist beyond the age of 6, consideration should be given to underlying conditions such as anxiety disorders, affective distress or PTSD.

In adults, untreated nightmare disorder may persist for decades.[6]

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Further reading and references

  1. Simor P, Bodizs R, Horvath K, et al; Disturbed dreaming and the instability of sleep: altered nonrapid eye movement sleep microstructure in individuals with frequent nightmares as revealed by the cyclic alternating pattern. Sleep. 2013 Mar 136(3):413-9. doi: 10.5665/sleep.2462.

  2. International Classification of Diseases 11th Revision; World Health Organization, 2019/2021

  3. Shneerson, J; Sleep Medicine: A Guide to Sleep and its Disorders, 2009

  4. Simard V, Nielsen TA, Tremblay RE, et al; Longitudinal study of bad dreams in preschool-aged children: prevalence, demographic correlates, risk and protective factors. Sleep. 2008 Jan31(1):62-70.

  5. Hasler B, Germain A; Correlates and Treatments of Nightmares in Adults. Sleep Med Clin. 2009 Dec4(4):507-517.

  6. Gieselmann A, Ait Aoudia M, Carr M, et al; Aetiology and treatment of nightmare disorder: State of the art and future perspectives. J Sleep Res. 2019 Aug28(4):e12820. doi: 10.1111/jsr.12820. Epub 2019 Jan 29.

  7. Markov D, Jaffe F, Doghramji K; Update on parasomnias: a review for psychiatric practice. Psychiatry (Edgmont). 2006 Jul3(7):69-76.

  8. Pagel JF; Nightmares and disorders of dreaming. Am Fam Physician. 2000 Apr 161(7):2037-42, 2044.

  9. British National Formulary (BNF); NICE Evidence Services (UK access only)

  10. Blagrove M, Morgan CJ, Curran HV, et al; The incidence of unpleasant dreams after sub-anaesthetic ketamine. Psychopharmacology (Berl). 2009 Mar203(1):109-20. doi: 10.1007/s00213-008-1377-3. Epub 2008 Oct 24.

  11. Eiser AS; Dream disorders and treatment. Curr Treat Options Neurol. 2007 Sep9(5):317-24.

  12. Bryant R; Post-traumatic stress disorder vs traumatic brain injury. Dialogues Clin Neurosci. 201113(3):251-62.

  13. Aurora RN, Zak RS, Auerbach SH, et al; Best practice guide for the treatment of nightmare disorder in adults. J Clin Sleep Med. 2010 Aug 156(4):389-401.

  14. Delirium; NICE Clinical Guideline (July 2010 - last updated January 2023)

  15. Silvestri R, Bromfield E; Recurrent nightmares and disorders of arousal in temporal lobe epilepsy. Brain Res Bull. 2004 Jun 3063(5):369-76.

  16. Nakajima S, Inoue Y, Sasai T, et al; Impact of frequency of nightmares comorbid with insomnia on depression in Japanese rural community residents: a cross-sectional study. Sleep Med. 2014 Mar15(3):371-4. doi: 10.1016/j.sleep.2013.11.785. Epub 2014 Jan 31.

  17. Trotti LM; REM sleep behaviour disorder in older individuals: epidemiology, pathophysiology and management. Drugs Aging. 2010 Jun 127(6):457-70. doi: 10.2165/11536260-000000000-00000.

  18. BaHammam AS, Almeneessier AS; Dreams and Nightmares in Patients With Obstructive Sleep Apnea: A Review. Front Neurol. 2019 Oct 2210:1127. doi: 10.3389/fneur.2019.01127. eCollection 2019.

  19. Moore M, Allison D, Rosen CL; A review of pediatric nonrespiratory sleep disorders. Chest. 2006 Oct130(4):1252-62.

  20. Hansen K, Hofling V, Kroner-Borowik T, et al; Efficacy of psychological interventions aiming to reduce chronic nightmares: a meta-analysis. Clin Psychol Rev. 2013 Feb33(1):146-55. doi: 10.1016/j.cpr.2012.10.012. Epub 2012 Nov 7.

  21. Zhang Y, Ren R, Sanford LD, et al; The effects of prazosin on sleep disturbances in post-traumatic stress disorder: a systematic review and meta-analysis. Sleep Med. 2020 Mar67:225-231. doi: 10.1016/j.sleep.2019.06.010. Epub 2019 Jun 22.

  22. Moturi S, Avis K; Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun7(6):24-37.

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